191592287-5-20-2022-28-AS-BTAO-CELVP5-20220520163611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592287
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:38:04 PM

Document Has Been Signed on 05/20/2022 04:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MASONIC HOMES FOR ADULTS		FACILITY NUMBER:	191592287
ADMINISTRATOR:	JUDY FIGUEROA		FACILITY TYPE:	741
ADDRESS:	1650 EAST OLD BADILLO ST		TELEPHONE:	(626) 251-2200
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	112	CENSUS: 54	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator, Sandy Fahey, and Facility Director, Bobbie Dimmitt		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Tao, Calderon and Maldonado conducted an unannounced annual inspection visit. LPA met with Administrator, Sandy Fahey, and Facility Director, Bobbie Dimmitt, both assisted with the visit. The facility was licensed to serve one hundred & twelve (112) non-ambulatory residents, ages 60 and above. The facility had an approved five (5) hospice waivers. Currently, three (3) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility locates at a residential neighborhood, consists of three (3) buildings with fifty-six (56) resident rooms. Resident rooms consists of a bedroom, living room, dining area, kitchen, bathroom and walk-in closet. LPAs visited resident rooms #A-104, A-110, B-109, B-113, and C-112. Bathrooms are clean and operable with grab bars and non-skid surface mats/strips. Hot water temperature is in a range of 107.7 to 117.9 degrees Fahrenheit which is within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies are in stock. The facility has six (6) administrative offices, a reception area/lobby, beauty salon, wellness center, 3 libraries, coffee/reading room, hospitality room, dining room, kitchen, mail room, communication room, activity /game room/painting/card making room, general store, housekeeping storage room, dental office (vacant), computer lab, nurses station, bingo room, exam room, staff lounge, and recovery room. There are multiple storage closets/rooms and an indoor/outdoor activity area. (-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MASONIC HOMES FOR ADULTS	FACILITY NUMBER: 191592287
	VISIT DATE: 05/20/2022

NARRATIVE

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The facility has fifteen (15) public restrooms which are clean and operational. There are four (4) residential laundry rooms and a maintenance laundry room. Sufficient supply of perishable and nonperishable foods were observed. Smoke and carbon monoxide detectors are operable, monitored by a fire alarm company which the last fire alarm inspection is conducted on 02/25/22. The facility has total of 85 fire extinguishers and LPAs checked ten (10) of them which are fully charged and last service was on 05/10/22. Elevator is operable and available for residents' use. Signal systems in resident rooms are operable. Swimming pool at the yard, pond at patio and jacuzzi at the first floor are empty with no water. They are locked, inaccessible to residents and surrounded with a 6-ft high fence. No bodily of water are observed in the facility.

The first aid kit is fully stocked with a manual. All mandated documents and signages are posted in common areas. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Medications are centrally, stored and locked and records are current. Fire/ Emergency drill conducted on 04/18/22. Facility landline phone is operable for residents' use. Administrator certificate is current with expiration day on 03/03/2023.

Exit conference was conducted. A copy of LIC 809s was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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